Shared decision-making among older adults with multimorbidity in Kerala's primary care: a qualitative study using the socio-ecological model.

Introduction: Multimorbidity is an increasing public health challenge among older adults, particularly in Kerala, India. Shared decision-making (SDM) is central to person-centered care for this group, yet its implementation remains inconsistent in low- and middle-income countries (LMICs). Methods: This qualitative study explored the experiences and perspectives of older adults with multimorbidity regarding SDM in Kerala's primary care. Sixteen adults (aged 60+) were recruited from four primary health centers using purposive sampling. The Socio-Ecological Model guided the design and thematic analysis, examining SDM influences at individual, interpersonal, organizational, and sociocultural levels. Results: Key findings revealed that individual barriers, such as limited health literacy and low self-efficacy, led to passive participation. Family members played a central role in healthcare interactions, sometimes facilitating but occasionally overshadowing patient voices. Organizational barriers, including high patient load and time constraints, limited SDM, while positive provider communication and continuity enabled engagement. Sociocultural factors included strong respect for medical authority and pluralistic health-seeking, with patients often reluctant to disclose alternative treatments to allopathic doctors. Exclusion from SDM was linked to dissatisfaction and poor adherence. Conclusion: Addressing these barriers and leveraging enablers will require coordinated efforts in communication, health literacy, family engagement, and culturally sensitive practice to advance person-centered care.